Doctors With Plenty of Time for Patients

Monday

Aug 29, 2011 at 12:01 AMAug 31, 2011 at 1:07 AM

Two new books — one on prostate cancer, the other on the sad state of medicine today — take a patient-centric approach.

ABIGAIL ZUGER, M.D.

Standard outpatient medical care affronts all logical time management. You wait for an appointment, you wait to be seen, and then comes the hectic series of milliseconds that constitutes the medical encounter itself. Before you remember half your agenda, you are firmly ushered on your way, down the exit chute to start the process all over again.

Suppose it were different, and you could actually rent the doctor’s attention for as long as you needed it? Suppose, for that matter, you could rent the actual doctor, propping that distinguished figure up by your bed to soothe your midnight terrors, and then resuming the dialogue in the morning?

There is no shortage of books aiming to provide exactly this experience: paper doctors to calm you through the night and bore you over breakfast. Many are written in such self-help generalities you might as well save your cash. But some are timely or original enough to warrant a careful look.

In the timely department is a new book by Dr. Arnold Melman, chief of urology at Albert Einstein College of Medicine in the Bronx, about coping with a diagnosis of prostate cancer. There is probably no more confusing part of the body these days than the prostate, at least in the sense that prostate cancer is confusing more doctors and patients than any other disease. Regulatory bodies cannot agree on the best screening strategies for this common illness. Meanwhile, the blood test used for screening has difficulty discriminating between aggressive and nonaggressive cancers, which means that standard cancer treatments are sometimes vastly worse than the disease itself.

Some doctors let their patients decide whether to be screened, and some men elect to skip the whole thing. Dr. Melman has seen too many men die from prostate cancer to be particularly sympathetic to this strategy. Instead, he operates from the position that men should want to know if they have cancer, and then should want to become cancer-free in short order.

A variety of treatment options will achieve this end; Dr. Melman and his co-author, Rosemary Newnham, a medical writer, deliver a detailed, straightforward and methodical description of them all. Illustrations help with the anatomy, and ample attention is paid to the severe side effects all these treatments can have.

The most common side effects are urinary incontinence and erectile dysfunction, both caused by surgical or radiation damage to the network of nerves traversing the prostate. Despite the newest amazingly capable surgical robots and finely tuned beams of radiation, either or both of these conditions may ultimately replace cancer as a man’s most significant medical problem.

“After Prostate Cancer” details everything that can be done to help, from Viagra and urinary catheters to a variety of additional surgeries. A final section is directed toward men whose cancer has spread; although they will probably die of the cancer, treatments can keep them well for a while.

There is nothing revolutionary in any of this; Dr. Melman is merely outlining what capable urologists know and do. What is unusual is the patient, unhurried, slightly pedantic but altogether reassuring tone. The man has all the time in the world for you, and for that reason alone this book may well supply the cancer patient with what he has difficulty finding elsewhere.

Dr. Steven Z. Kussin, by contrast, addresses not a particular group of patients but the world at large. A bad car accident 10 years ago prompted him to reflect at length on the “process and philosophy” of medical care, and his book is an encyclopedic treatise on the sad state of medicine today and the best ways for an Internet-savvy consumer to cope.

Dr. Kussin, trained as a gastroenterologist, is a talker. One suspects that even in the office he was never one to hurry folks along. With the luxury of print he waxes supremely chatty.

Some of his ruminations are sphinxlike (“Trusting your fate to strangers with fingers crossed is the beginning of a star-crossed course”). Some are on the far edge of controversial, like diatribes against clinical trials and hospitalists (doctors who take over your care if you are admitted): he says both are likely to endanger the average patient’s welfare.

He also offers the occasional nugget of unusual advice. Should you really send your doctor a birthday card and gift to get better care, as he suggests? As bad as things are out there, one does like to think this particular precaution has not yet become necessary.

The sardonic commentary loops on — Kurt Vonnegut meeting Miss Manners — as Dr. Kussin settles himself down at the edge of your bed for a nice long lecture. “Don’t be an annoying evening telemarketer,” he cautions. (In other words, call a covering doctor only when absolutely necessary.) “Don’t venture into what is surely one of Dante’s Nine Circles of Hell with only a boo-boo.” (Steer clear of emergency rooms except in a true emergency.) “Going to a top hospital means nothing if you are about to be cared for by that name-brand hospital’s village idiot.” (Amen to that.)

Dr. Kussin does offer comprehensive advice on using medical Web sites to advantage, but the casual reader may still find his company a little too much monologue and too little dialogue. Still, for future sociologists, this book will serve as an invaluable guide to the echoing chambers of the 2011 doctor’s mind.

AFTER PROSTATE CANCER A What-Comes-Next Guide to a Safe and Informed Recovery. By Arnold Melman, M.D., and Rosemary E. Newnham. Oxford University Press. 256 pages. $19.95.